Attachment E

ARKids 1ST PROTOTYPE

DISCLOSURE OF FREE AND REDUCED PRICE ELIGIBILITY INFORMATION

AGREEMENT

  1. PURPOSE AND SCOPE

(Insert name of determining school) and (insert name of receiving agency) acknowledge and agree that children’s free and reduced price meal and free milk eligibility information obtained under provisions of the National School Lunch Act 942 USC 1751 et. seq.) or Child Nutrition Act of 1966 (42 USD 1771 et. seq.) and the regulations implementing those Acts is confidential information. This Agreement is intended to ensure that any information disclosed by the (insert name of determining school) to the (insert name of receiving agency) about children eligible for free and reduced price meals or free milk will be used only for purposes specified in this Agreement and that the (insert name of determining agency) and (insert name of receiving agency) recognize that there are penalties for unauthorized disclosures of this eligibility information.

  1. AUTHORITY

Section 9(b)(2)(C)(iii) of the National School Lunch Act (42 USC 1758(b)(2)(C)(iii)) authorizes the limited disclosure of children’s free and reduced price meal or free milk eligibility information to specific programs or individuals, without prior parent/guardian consent. Except that, the parent/guardian must be provided the opportunity to decline to share eligibility information prior to the disclosure for identifying children eligible for benefits under or enrolling children in the State Medicaid Program and the State children’s health insurance program. Additionally, the statute specifies that for any disclosures not authorized by the statute, the consent of children’s parents/guardians must be obtained prior to the disclosure.

The requesting agency certifies that it is currently authorized to administer the following program and that information requested will only be used for:

Program

/

Information authorized

Medicaid or the State children’s health insurance program (SCHIP), administered by a State or local agency authorized under titles XIX or XXI of the Social Security Act. / All eligibility information, unless elect not to have information disclosed.

Section 9(b)(2)(C)(iv) specifies that for State Medicaid or SCHIP, parents must be notified and given opportunity to elect not to have information disclosed. Social Security numbers may only be disclosed if households are given notice of the disclosure and the uses to be made of their social security numbers as required by Sec. 7 of the Privacy Act.

III.SAMPLE AGREEMENT – Disclosure of Eligibility

  1. (Insert Name of Determining School) will:

When required, secure parents/guardians consent prior to any disclosure not authorized by the National School Lunch Act or any regulations under that Act, unless prior consent is secured by the receiving agency and made available to the determining agency;

For State Medicaid and SCHIP, notify parents/guardians of potential disclosures and provide opportunity for parents/guardians to elect not to have information disclosed;

Disclose eligibility information only to persons directly connected to the administration or enforcement of programs authorized access under the National School Lunch Act or regulations under the Act or to programs or services for which parents/guardians gave consent.

  1. (Insert Name of Receiving Agency) will:

Ensure that only persons who are directly connected with the administration or enforcement of the (insert name of the Program) and whose job responsibilities require use of the eligibility information will have access to children’s eligibility information:

(Specify by name(s) or title(s))______

______

______

Use children’s free and reduced price eligibility information for the following specific purpose(s):

(Describe)______

______

______

Inform all persons that have access to children’s free and reduced price meal eligibility information that the information is confidential, that children’s eligibility information must only be used for purposes specified above, and the penalties for unauthorized disclosures.

Protect the confidentiality of children’s free and reduced price meal or free milk eligibility information as follows:

(Specifically describe how the information will be protected from unauthorized uses and further disclosures)______

______

______.

C.Description of Procedures to Transfer Meal Eligibility Information (May be completed by either the determining agency or receiving agency):

Describe the procedures for transferring students’ meal eligibility information from the determining agency to the requesting agency/program so as to limit the number of individuals who have access to the information.

(Describe)______

  1. EFFECTIVE DATES

This agreement shall be effective from ______to ______.

  1. PENALTIES

Any person who publishes, divulges, discloses, or makes known in any manner, or to any extent not authorized by Federal law (Section 9(b)(2)(C) of the National School Lunch Act; 42 USC 1758(b)(2)(C)) or a regulation, any information about a child’s eligibility for free and reduced price meals or free milk shall be fined not more than a $1,000 or imprisonment of not more than 1 year or both.

  1. SIGNATURES

The parties acknowledge that children’s free and reduced price meal and free milk eligibility information may be used only for the specific purposes stated above; that unauthorized use of free and reduced price meal and free milk information or further disclosure to other persons or programs is prohibited and a violation of Federal law which may result in civil criminal penalties.

Requesting Agency/Program Administrator

Printed Name:______

Title:______Phone:______

Signature:______

Date:______

Determining Agency Administrator

Printed Name:______

Title:______Phone:______

Signature:______

Date:______

*Any attachments will become part of this agreement.

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